Endometriosis and Menopause: HRT, Perimenopause and What to Expect

If you have endometriosis and are approaching perimenopause or menopause, questions about HRT, symptoms, and what to expect can feel overwhelming. This page brings together clear, evidence-based guidance to help you understand your options and feel confident in your care.

Overview

Endometriosis and menopause are two conditions that are often discussed separately, but for many women they are deeply intertwined. If you have been living with endometriosis, the perimenopause and menopause transition brings a new set of questions, about symptoms, about hormones, about whether treatment is safe, and about what to expect.

Whilst treatment decisions need to be individualised, with specialist input, most women with endometriosis are able to manage this transition effectively and protect their long-term health.

What is endometriosis?

Endometriosis is a condition in which tissue similar to the lining of the uterus grows outside it, most commonly in the pelvis, on the ovaries, fallopian tubes, bladder, or bowel. It affects around one in ten women and people with a uterus, and is often under-diagnosed or diagnosed late.

Endometriosis is best understood not simply as a gynaecological problem, but as a multi-system neuroendocrine inflammatory condition. This definition matters because it helps explain the full picture of what living with endometriosis involves:

  • It is driven by hormones, particularly oestrogen, which is why it is affected by the menopause transition
  • It involves chronic inflammation, which has effects throughout the body, not just in the pelvis
  • It can cause changes to the nervous system over time, including central sensitisation, a process in which the pain processing system becomes heightened and more reactive. This means symptoms can persist even when hormone levels fall, and explains why endometriosis does not always respond to hormone based treatment alone
  • It can affect energy, mood, cognition, bowel and bladder function, and overall quality of life, not just pelvic pain and periods

Many women with endometriosis also have co-existing conditions, including adenomyosis (where similar tissue grows within the muscle wall of the uterus), fibroids, interstitial cystitis, irritable bowel syndrome, anxiety, and depression. Understanding this context is important, because it shapes how the menopause transition is experienced and managed.

What happens to endometriosis at perimenopause and menopause?

Because endometriosis is oestrogen-sensitive, declining oestrogen levels during the menopause transition often can lead to a reduction in symptoms over time. For many women, the disease becomes less active after menopause.

However, this is not universal. Some women experience a worsening of symptoms during perimenopause, particularly during the phase of hormonal fluctuation that precedes menopause. This can be confusing and distressing, especially if you had hoped the menopausal transition would bring relief.

After natural menopause, endometriosis lesions typically become inactive, but deep infiltrating disease or previously excised areas may continue to cause symptoms in some women. This is particularly relevant if you are considering hormone replacement therapy.

Adenomyosis, which frequently co-exists with endometriosis, often causes significant symptoms during perimenopause, including heavy bleeding, pelvic pressure, and pain, which can overlap with and compound perimenopausal symptoms.

If changes are needed, we can adjust one element of your treatment without altering the entire regime.

Surgical menopause and endometriosis

Some women with endometriosis undergo treatment which results in surgical menopause, meaning the ovaries are removed (bilateral oophorectomy), sometimes alongside a hysterectomy (removal of the uterus), either as a treatment for the disease or as part of wider surgery.

Surgical menopause is different from natural menopause in that the loss of oestrogen is abrupt and complete, rather than gradual. This typically causes more severe and sudden symptoms, and carries greater long-term health risks if left untreated.

HRT is recommended for most women following surgical menopause, at least until the age of 51, in line with guidance from the British Menopause Society (BMS) and NICE. The benefits, for symptoms, bone health, heart health, and cognitive wellbeing, are significant, and the risks of not treating are well established.

While micronised progesterone is usually better tolerated, some people still experience symptoms with it. Others find that certain progestins suit them better than progesterone itself, or that one type of progestogen is more tolerable than another.

The progesterone question

If you have had a hysterectomy, you usually do not need progestogen to protect the womb lining, because you no longer have a womb. In most women, this means oestrogen-only HRT is the standard approach following hysterectomy.

However, in women with a history of endometriosis, the picture is more nuanced. BMS guidance recommends that combined HRT (oestrogen plus progestogen) should be considered even after hysterectomy, because residual endometriotic tissue may remain in the pelvis and can still respond to oestrogen.

If this happens, it could potentially cause a flare of endometriosis, and therefore the this needs to be avoided to avoid a return of symptoms and resulting complications.

There are also very rare but documented cases of malignant change in residual endometriosis deposits exposed to long-term unopposed oestrogen eg oestrogen only HRT. This risk is generally extremely low, but it does need to be considered and often mitigated against.

Where combined HRT is used, the type of progestogen matters. Micronised progesterone (Utrogestan) is often a good option for women with concerns about progestogen side effects, given its more favourable tolerability profile and reduced breast cancer risks compared with other progestogens, but it is important that this choice is carefully considered and individualised.

Symptoms may begin soon after starting treatment, or sometimes are slightly slower to develop. They can vary in severity; for some women they are very mild, but for others can be very disruptive.

For some people, progesterone intolerance can be a barrier that prevents HRT from feeling beneficial, even when oestrogen improves other symptoms.

There can be a lot of overlap between the symptoms of progesterone intolerance and the symptoms of perimenopause and menopause itself, making it tricky to identify at times. It is always important to discuss progesterone intolerance symptoms with your GP or menopause specialist so they can help you to establish whether symptoms are purely related to progesterone itself or whether there is also an element of unmanaged perimenopausal or menopausal symptoms.

This is an individualised decision. The extent of disease at the time of surgery, whether excision was complete, your symptom history, and your overall health picture all inform what is right for you.

HRT and endometriosis: can I take it?

Fear about using HRT is common in women with endometriosis. Many have been told, sometimes in passing, sometimes quite firmly, that oestrogen feeds endometriosis and should be avoided. It is understandable that this leaves women reluctant.

The concern is not entirely without basis: endometriosis is oestrogen-sensitive, and this is a legitimate clinical consideration. But context matters enormously here.

The doses of oestrogen used in HRT are considerably lower than the levels the body was naturally producing before menopause. In effect, HRT brings oestrogen back to a level closer to what your body was already managing, it does not add oestrogen in the way that might actively drive disease.

The BMS and NICE both support the use of HRT in women with endometriosis going through the menopause transition. Where the uterus is still present, a combined preparation (oestrogen plus progestogen) is used. Where continuous combined HRT is used, rather than sequential or cyclical preparations, this avoids the cyclical hormonal changes that can stimulate residual lesions.

The risks of untreated menopause are real and significant: accelerated bone loss, increased cardiovascular risk, cognitive changes, genitourinary symptoms, and reduced quality of life. For women who have had a surgical menopause, these risks are particularly pronounced because oestrogen loss is sudden and complete.

Local oestrogen (vaginal oestrogen cream or pessaries) for genitourinary symptoms is safe, effective, and frequently underused in this group. It works locally, is minimally absorbed systemically, and can make a significant difference to urinary symptoms, vaginal comfort, and sexual health.
Regular review is important. Symptoms change, circumstances change, and your HRT regimen should be revisited regularly with a specialist who understands your full history.

Symptoms: what is endometriosis and what is menopause?

One of the most confusing aspects of this period is working out what is driving your symptoms. Many of the symptoms of perimenopause overlap significantly with those of endometriosis, and if you also have adenomyosis, fibroids, or bladder symptoms, the picture can become even harder to unpick.

  • Symptoms that can be features of both conditions include:
  • Fatigue and low energy
  • Pelvic and abdominal pain
  • Bladder urgency or frequency
  • Bowel symptoms, including bloating, cramping, or altered bowel habit
  • Mood changes, anxiety, or low mood
  • Brain fog and difficulty concentrating
  • Sleep disruption
  • Changes in libido

A specialist review can help to tease apart what is most likely to be driving different symptoms, and tailor a management plan accordingly. It is rarely a case of one diagnosis or the other, more often, it is both, with each needing attention.

Emotional and psychological impact

Living with a chronic pain condition and then navigating a significant hormonal transition is not a small thing. Many women with endometriosis have experienced long diagnostic journeys, dismissal, repeated treatments, and a complicated relationship with their own body. Arriving at perimenopause can bring a mix of grief, relief, uncertainty, and fear, sometimes all at once.

There may be feelings of loss, around fertility, around identity, around a hoped-for version of this transition that does not match the reality. There may also be a kind of exhaustion from years of managing a condition that has taken up so much space.

Psychological and emotional support is not an add-on to clinical care in this context, it is part of it. Whether that is space to process what is happening, support with wellbeing strategies, or simply being heard by a clinician who takes the whole picture seriously, it matters.

Symptom tracking can be invaluable. Keeping a record of symptoms, medication changes, and menstrual patterns helps establish whether there is a clear relationship between progesterone exposure and symptom onset.

Long-term health considerations

The menopause transition has long-term health implications for all women, but for women with endometriosis, particularly those who have had a surgical menopause, some of these are heightened.

Bone health

Oestrogen plays a key role in maintaining bone density. Early or surgical menopause without treatment significantly increases the risk of osteoporosis. HRT is the most effective intervention, alongside adequate vitamin D and calcium, and regular weight-bearing and resistance exercise. A baseline bone density scan (DEXA) is often appropriate.

Cardiovascular health

Loss of oestrogen is associated with increased long-term cardiovascular risk. This is particularly relevant following surgical menopause. Hormone replacement, combined with attention to blood pressure, cholesterol, activity levels, and stress, forms part of a comprehensive approach.

Pelvic floor and genitourinary health

Genitourinary symptoms, including vaginal dryness, urinary urgency, and discomfort, are common in menopause and may be compounded by a history of endometriosis, pelvic surgery, or pain. Local oestrogen is safe and effective and is often recommended alongside systemic HRT. Pelvic floor physiotherapy can also be valuable and is underutilised in this group.

Lifestyle support

Lifestyle measures will not replace oestrogen, and they are not an alternative to appropriate medical treatment. But they are a genuinely important part of the picture, and in the context of a multi-system inflammatory condition combined with a major hormonal transition, they become even more relevant.

Nutrition and inflammation

Both endometriosis and the menopause transition are associated with inflammation. An anti-inflammatory dietary pattern, rich in oily fish, vegetables, legumes, wholegrains, and good quality fats, supports both conditions in the same direction. There is no need for a rigid or restrictive approach; consistent, varied, and predominantly whole-food eating is the goal. Gut health is worth particular attention given how frequently bowel symptoms feature in this picture.

Movement

Regular movement supports pain modulation, bone density, cardiovascular health, mood, and energy, all relevant here. Consistent, sustainable movement is more valuable than intensive exercise that feels punishing. For women with a history of chronic pain or post-surgical recovery, gentler starting points are often more appropriate. Strength and resistance work becomes increasingly important in the menopause transition for bone and metabolic health.

Nervous system support

This is genuinely relevant here, not as a euphemism for stress management, but as a recognition of the physiology. Endometriosis involves changes to pain processing and nervous system regulation over time. Perimenopause adds further hormonal volatility. Practices that support nervous system regulation, including breathwork, yoga, somatic movement, good sleep, and time in nature, have real relevance in this context, and the evidence base for their impact on pain, mood, and wellbeing is growing.

Sleep

Disrupted sleep is common in both perimenopause and endometriosis, and the relationship is bidirectional, poor sleep worsens pain, mood, and inflammation, and pain and night sweats worsen sleep. Actively addressing sleep is worth prioritising, not just accepting.

At Manchester Menopause Hive, we have extensive experience supporting women with progesterone intolerance. We take time to listen, assess your individual situation, and work collaboratively to find an approach that works for you.

Our approach

At Manchester Menopause Hive, we see many women with endometriosis navigating the perimenopause and menopause transition, both in our Hale clinic and online across the UK. It is a combination that requires unhurried, specialist attention, not a one-size-fits-all approach.

We offer specialist, individualised care that takes into account your full history: the course and treatment of your endometriosis, any surgery you have had, your current symptoms, your long-term health priorities, and your life context. We work with BMS and NICE guidance and stay current with the evidence.

Our approach is not just about getting the prescription right, though that matters. It is also about helping you understand what is happening in your body, making sense of symptoms that can feel bewildering, and supporting you to feel confident in your care.

Our aim is to help you feel supported, heard, and confident in your treatment plan.

When to seek specialist advice

You should consider a specialist review if:

  • You have endometriosis and are experiencing perimenopausal or menopausal symptoms
  • You have had a hysterectomy with or without oophorectomy and are unsure about HRT
  • You have been told HRT is not suitable for you because of endometriosis
  • Your symptoms are poorly controlled or difficult to attribute
  • You have had a surgical menopause and are not currently on HRT
  • You have concerns about long-term bone or cardiovascular health

Helpful resources

Progesterone intolerance FAQs

Can I take HRT if I have endometriosis?

Yes, for most women. Both NICE and the BMS support the use of HRT in women with endometriosis. The type, formulation, and regimen will depend on your individual history, including whether you have had surgery and to what extent. A specialist review can help determine the right approach for you.

Do I need progesterone if I have had a hysterectomy for endometriosis?

Usually, yes, even without a uterus. BMS guidance recommends that women with a history of endometriosis who have had a hysterectomy should be considered for combined HRT (oestrogen plus progestogen), because residual endometriotic tissue can remain in the pelvis and may respond to unopposed oestrogen. This is an individualised decision that should be discussed with a specialist.

Will menopause cure my endometriosis?

For many women, symptoms improve significantly after menopause as oestrogen levels fall. However, this is not guaranteed. Some women continue to experience symptoms, particularly if deep infiltrating disease is present or if the nervous system changes associated with chronic pain persist. HRT does not mean returning to premenopausal oestrogen levels, it is a much lower dose.

What type of HRT is recommended for women with endometriosis?

Continuous combined HRT, oestrogen plus progestogen taken together without a break, is generally preferred over cyclical or sequential regimens, as it avoids the cyclical hormonal fluctuations that can stimulate residual lesions. Micronised progesterone (Utrogestan) is often the preferred progestogen. Your regimen should be tailored to your individual circumstances and reviewed regularly.

I have had a surgical menopause: should I be on HRT?

In most cases, yes. Surgical menopause causes an abrupt loss of oestrogen and is associated with significant short- and long-term health risks if untreated. NICE and the BMS strongly recommend HRT following surgical menopause unless there is a clear medical contraindication. If you have been advised against it, a second specialist opinion is worthwhile.

Can HRT make endometriosis worse?

This is unlikely at the doses used in standard HRT preparations, which are much lower than the oestrogen levels your body produced naturally before menopause. The risk of disease reactivation with appropriately prescribed HRT is considered low. Using continuous combined HRT rather than cyclical preparations further reduces the likelihood of stimulating residual tissue.

How do I know if my symptoms are endometriosis or perimenopause?

This is a genuinely difficult question, and often the honest answer is that it is both. Many symptoms, fatigue, pelvic pain, bowel changes, mood changes, bladder symptoms, and brain fog, are common to both conditions. A specialist review, taking your full history into account, can help identify what is most likely to be driving different symptoms and how best to address them.

What is adenomyosis and how does it relate to endometriosis?

Adenomyosis is a related condition in which endometrial-like tissue grows within the muscular wall of the uterus, rather than outside it. It frequently co-exists with endometriosis and can cause heavy periods, pelvic pressure, and pain. It is worth discussing with your doctor if you have endometriosis, particularly during perimenopause when bleeding patterns often change.

What if my GP says HRT is not suitable because I have endometriosis?

This is a situation where a second specialist opinion is always appropriate. The evidence base and current clinical guidance support HRT use for most women with endometriosis, with appropriate formulation choices. A BMS-registered menopause specialist can review your history and help determine the safest and most effective approach for you.

Does endometriosis affect bone health?

Yes, indirectly. Early or surgical menopause without treatment significantly increases the risk of osteoporosis, and women with endometriosis who have had surgery at a younger age are at particular risk. HRT is the most effective way to protect bone density, alongside lifestyle measures. A baseline DEXA scan is often appropriate.

Endometriosis and menopause together can feel complicated. Our job is to help you make sense of it.

If you have endometriosis and are navigating perimenopause or menopause, a specialist appointment can help bring clarity, confidence, and a plan that is right for you.

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